Golfer’s Elbow and Massage Therapy

With spring approaching, days getting longer, golfers might just about be thinking about getting the clubs out of the garage, sorting the golf bag out, debating whether to eat or throw out that uneaten bar of chocolate……was this one left in here from last year, or the previous year?

It’s a time filled with eager anticipation for the coming season.

Nobody wants it ruined by a painful elbow.

Golfer’s elbow a.k.a. ‘medial epicondylitis’ (ep-ih’-con-dil-i’-tis) can affect people who play golf, and people who have never hit a golf ball in their life.

What is it?

It’s a painful condition of the elbow, particularly the knobbly bit nearest to your body if you were standing with your arms close to your side, elbows bent and palms facing upwards… roughly the point on the inside of your elbow that’s about level with the bottom rib that you can feel.

The medical name of medial epicondylitis is given because it affects the medial epicondyle of the humerus bone (the side nearest the body when standing in the anatomical position)
Each humerus (upper arm bone) bone has 2 condyles and 2 epicondyles- ‘Condyles’ are the knobbly bony bits at the elbow joint end of the humerus. The ‘epicondyles’ are the outer sides of these knobbly condyles.

A condition that ends in an ‘itis’ means there is inflammation of some sort. ‘Epicondylitis’ means that there is inflammation of the tendon attaching the muscle to the epicondyle. However, research has shown that contrary to previous thinking, inflammation is generally not a component of many hand and wrist conditions such as lateral (tennis elbow) and medial epicondylitis (golfers’ elbow) (Fairweather & Mari , 2005). In actual fact, a more correct term would be be epicondyl-‘osis’ (‘osis’ meaning disease or pathological process, or a non-inflammatory process, generally suggesting degeneration of the tendon due to overuse/repetitive action).

Who gets it?

It is definitely not restricted to golfers. Anyone can get it from repeated gripping actions. Golfers get it from repeatedly striking the golf ball with a club, particularly if the wrist bends forward on the follow through.

Signs and Symptoms

The main symptoms are tenderness and discomfort on the inside of the elbow, with pain that gets worse with movement or during a full stretch. Sometimes, but not always, there is swelling at the area too. Weakness and the ability to grip fully can occur due to pain.

Healing time- it takes patience!

Average healing time for tendinitis ranges from a few days to 6 weeks and for tendinosis between 3 and 6 months because degenerated tendons take over 100 days to produce new collagen. (Khan et al 2000).

Causes

It’s caused by irritation of the common flexor tendon at the medial epicondyle of the humerus. It could also be the result of factors such as injury, direct trauma, ageing/ degenerative change, overuse or joint disease.

The flexor muscles of the forearm are the ones that are involved in bending the wrist in such a way that the palm of the hand and fingers come up towards the inside soft bit of the arm. These flexor muscles join together to form a common flexor tendon that attaches to the medial epicondyle and it is the irritation to that tendon that causes the pain on the inside of the elbow.

There a lovely quote on the subject of irritation by Harry Emerson Fosdick

“The most extraordinary thing about the oyster is this. Irritation gets into his shell. He does not like them. But when he cannot get rid of them he uses the irritation to do the loveliest thing an oyster ever has the chance to do. If there are irritations in our lives today, there is only one prescription: make a pearl. It may have to be a pearl of patience, but…make a pearl.”

However, there is nothing lovely like a pearl produced here. Golfers elbow is a very painful and debilitation condition and without proper intervention it can seriously impact on normal day to day activities as simple as opening a jar, gripping a handle, holding the steering wheel or bicycle handlebars, or wringing out a cloth.

The patience part though, is very apt. This condition needs patience.

What’s affected?

Muscles, tendons, ligaments, bones, joints, fascia, skin……and mood! While it present as a physical condition if long term pain is involved or there is restriction of activities or a sport that is enjoyed, then mood will very likely and very understandably be affected too.

Massage Therapy to treat Golfer’s elbow

First of all, a full consultation with the client takes place. Assessment of range of active, passive and resisted movement will be carried out to ascertain where there is pain and/or restricted range of movement. In addition to the affected joint, the joints above and below are assessed.

Range of Movement and level of pain are ideal for assessing progress however it’s very  useful for the client to tell the therapist what normal day to day activities are affected – for example – I can’t open a jar without pain or I can’t grip a golf club or wring out my facecloth. These are good measures for assessing results.

An important stage in rehabilitation is for the client and therapist to discuss and agree a treatment plan and timescale and to confirm what good progress or a target would look like – for example, in 6 weeks to be opening a jar without pain.

Goals need to be realistic, measurable and achievable. If a condition has been present for 2 years, it’s probably not going to be fully resolved in 2 treatments. Additionally, clients need to be totally honest in regards to the exercise and rest regime they can invest in their rehabilitation. With best intentions, they may think they can do the required rehab but life takes over sometimes.

Rome wasn’t built in a day.

Techniques used

Massage treatment could include the use of heat to help release muscles before fascial and trigger point work. The fascia is the outer sheath that surrounds the muscles and trigger points are areas within the muscle that are normally characterised by the fact they refer pain to another part of the body.

Hot stones or warm bamboo sticks could also be used during treatment.

Fascial work such as cross hand strokes to put the tissue on a stretch could be used as could myofascial spreading, traction, soft tissue technique (pin and stretch), trigger point therapy, deep tissue massage, cross fibre friction and muscle energy techniques. The use of cold therapy could be soothing at the point of insertion of the tendon onto the epicondyle.

There are a lot of valuable tools in the massage therapist’s bag and it depends on each unique situation as to what techniques are most appropriate.

The areas of the body being treated

The body is complicated. Muscles and structures don’t work in isolation so they have an effect on other parts of the body. A client might wonder why with a sore arm, the therapist is treating their neck, but it is up to the therapist to explain to the client why the other areas are important in the treatment (a lot of arm pain actually comes from the neck). Pain and tension in one area can cause pain and tension in other areas.

In the case of golfers elbow, treatment would include the forearm flexors and extensors, the hand and fingers, the muscles of the upper arm and the muscles responsible for turning the arm – palm up/ palm down. It may also very likely include treatment of the shoulder area, upper back, Pectoralis muscles and neck muscles.  Even if the other arm was showing no pain, it may also be treated if appropriate.

Re-assessment

Following treatment and reassessment of the Range of Movement and level of discomfort, the therapist and the client should agree a treatment plan which would include follow up visits but may also include some exercises or self-care for the client to do before returning.

Self care

Rest is vital in recovery. This is not what the enthusiastic golfer wants to hear. Mood can be negatively affected when activity is curtailed. It’s perhaps a time to think about doing an alternative exercise temporarily during the rehab phase to alleviate boredom and maintain fitness. This could include activities which either have no impact on the forearm or can be adapted to avoid strain such as regular walking, Pilates or yoga. Relaxation is fundamental in promoting a feeling of wellbeing and allowing the body to recover. A holistic approach incorporation soothing massage techniques into a remedial massage treatment is also helpful.

Heat such as a warmed pad or warm hot water bottle wrapped in a soft towel can be soothing. Gentle pin and stretch techniques applied by the client to their own arm after demonstration by the therapist can be useful if done properly.

Resources

Jing Advanced Massage Training in Brighton have produced some helpful self-care resources which can be downloaded.

• Helpful visualisations for pain relief (something to try if you’re lying awake in pain and the rest of the world seems to be sleeping)
• Catastrophising (avoiding the ‘I’ll never play golf again’ mind-set)

References

Fairweather, R., & Mari , M. S. (2005). Massage Fusion: The Jing Method for the Treatment of Chronic Pain. Edinburgh: Handspring.

Finando, D.; Finando, S. (2005). Trigger Point Therapy for Myofascial Pain. Vermont: Healing Arts
Press

Salvo, S.G. (2018). Mosby’s Pathology for Massage Therapists 4 th Edition. St Louis, Missouri: Elsevier
Inc